Final Report

READ FINAL REPORT: Frail Elderly Project - (.PDF)

The Frail Elderly Project’s research and recommendations focus on seniors, but contain relevant improvements that could improve health care for most Vermonters. The recommendations are based on five complementary research arms designed to highlight the priorities of seniors themselves regarding their health and the quality of life.

Underlying project recommendations are research findings that are remarkably consistent across all five project research arms:

  1. There are mismatches between what gets paid for and what’s important to seniors;
  2. Today’s payment policies create significant inefficiencies and harm Vermont’s seniors;
  3. Personal finances matter; and many seniors get caught “in the middle” between eligibility for public support and sufficient personal resources
  4. Physical health matters to seniors, but remaining at home, retaining autonomy, social engagement and feeling useful and valued matter at least as much;
  5. Care should go to patients rather than patients having to come to care;
  6. Control over health care budgets needs more community level influence;
  7. Primary care is in critical condition, and we all need to rethink how to support it;
  8. There are proven examples of how to do it better; and
  9. There is a lot that can be done right now!

Our recommendations are all founded on what we were told by seniors, by community based clinical practitioners and support service providers who aid their elders every day, from Vermont subject matter experts and from a review of  published literature with the assistance of our University library system. The recommendations are our sincere attempt to design a care model that reflects what we were told or has been published in the peer reviewed literature. We anticipate and encourage serious discussion about our recommendations. We also encourage efforts to increase the breadth or depth of our research where needed. That being said, we hope that discussion and policy will not spin away from what seniors say matters to them and the knowledge of their caregivers who know them so well. Our recommendations are presented as answers to four core questions: 1) Who are our high risk seniors? 2) How will we measure success? 3) How will we care for them? And, 4) How will we pay for their care?

1) Who are our high risk seniors?

A three-step identification process is recommended. Initially, existing data such as billing data and structured data in medical records for all patients known to a practice should be screened for significant events, high utilization patterns, key diagnoses, social determinants of health and impairment in ADLs and IADLs if available. The resulting list of Identified patients should be reviewed for appropriateness by a dedicated practice senior care team.  Subsequently practice team members can recommend additional patients known to them to be at risk of poor health outcome or a decline in the quality of their lives.  All partner community support service providers are invited to recommend additional people in the community.

2) How will we measure success?

A multi-dimensional evaluation is recommended.  No single index of success is sufficient. Existing validated metrics should be used. Annual comparisons to appropriate benchmarks should be utilized rather than pre and post measures. The evaluation should include measures in the following domains:

  • Social, health behavioral, clinical and mental health;
  • Functional measures including patient reported outcomes, measures of patient goals being met and independence with sufficient support;
  • Provider reported process and outcome measures including measures of access, satisfaction, number of patients at meeting goals, number of eligible patients and number of patients removed from list; and, 
  • Utilization and financial measures including hospitalization, ED visits and long term nursing home placement and claims paid and site of service.

3) How will we care for them?

Each senior in the high risk group will have a comprehensive initial assessment by the practice’s multidisciplinary Primary Care Team. Key members of the Team will be the primary medical practitioner, a practice nurse, the practice’s integrated care coordinator and the patient and/or their caregiver. The assessment will include a visit to the patient’s home and a discussion of needed home based services to support independence. Based on the assessment every high risk senior will have a Care Plan with guidance for the patient, for the family and for both clinical and community support providers. 

Outside of the practice, but including key representatives of the practice team, will be a Neighborhood Team. The Neighborhood Team will include representatives of appropriate community support and service providers with the patient and family’s consent. The Neighborhood Team will meet with sufficient frequency to review new and emergency cases as well as periodic reviews of all high-risk seniors in the community.  Patients and families will always be able to choose not to have their Care Plan discussed outside of the practice; their privacy concerns will be respected.

A third layer of community coordination will occur at periodic meetings of representatives of both practice and community partners. This tertiary level of coordination will focus on the adequacy of the overall needs of the community’s seniors and available local, state and federal resources and serve as a focus for community advocacy for their senior citizens.

4) How will we pay for their care?

Several funding mechanisms are in operation in the US and Canada that support all parts of the recommended care model.  None of them support all the components of the recommended model or don’t cast a wide enough net to capture all the high risk seniors in our rural communities.  A few programs will be presented to highlight key issues including the Commonwealth Health Alliance’s Senior Options Program and the CMS demonstration project, Independence at Home. We are highlighting these two programs because they are in operation presently, demonstrate remarkable success in delivering care in a manner that matters to seniors and illustrate the potential for innovative care models and payment policy. The reader should be cautioned that eligibility for both these programs is directed at seniors with either the most limited financial resources or a very high need of clinical care. If these programs were to be implemented as is in the two target Vermont communities, many seniors would be left out.  However, elements of both these programs, if adapted to address the needs of Vermont’s high-risk seniors, would be an improvement over the status quo.

The paramount issue about payment is that a payment methodology should be the last question to be addressed.  What matters to seniors as presented in the project findings needs to always be of primary importance and the final guide to any decisions about care model design, measures of success and funding mechanisms to support care.

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